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Utilization Management: Rules, Regulations and How-To’s
Recorded Webinar
The Centers for Medicare and Medicaid Services (CMS) provides us with two Conditions of Participation that apply to the work of case management professionals. These include the Conditions of Participation for Discharge Planning and the Conditions of Participation for Utilization Review. This webinar will focus on these rules as they apply to the role of utilization review. In order for case management departments to be compliant with these regulations, RN and social work case managers must understand these ‘rules of the road’ for utilization review and work within their boundaries.
In this jam-packed program you will learn how to stream-line your utilization management process as well as understand the Conditions of Participation for Utilization Review and how they impact on your work as a case manager. We will discuss the differences between utilization review and utilization management. The process for incorporating medical necessity into the process of utilization management will be explained. This will be followed by a discussion of the compliance components for utilization review including the utilization management plan, the utilization management committee, Condition Code 44, and the two-midnight rule. How to incorporate the two-midnight rule into your utilization management process. Also explained will be the various types of clinical reviews performed by the case manager.
The various types of Hospital-Issued Notices of Non-Coverage (HINNs) will be described with examples of how they are used. You will learn whether or not your utilization management committee is effective and compliant.
Venue: Recorded Webinar
Telehealth completely changed in 2020 when the Public Health Emergency was put into effect. Now in 2025, many of those temporary changes are expiring and the telehealth business has exploded. These methods of communication between provider and patient are loved by many, and the convenience of telehealth in healthcare has become a common occurrence. This webinar will be reviewing the current parts of telehealth that are being considered permanent in the 2026 Physicians Fee Schedule Final Rule and the new evaluation and management services that are new codes for CPT in 2025 related to telehealth. We will find out what the do’s and don’ts of telehealth that are here to stay, as well as implementing these new codes and regulations into your practice. These new rules and codes are important to any one currently offering telehealth as well all who are considering it to add it to their practice in order to be compliant and maximize reimbursement for the services performed. Areas Covered in this Webinar The CMS Telehealth List and how to use it Medicare’s rules G codes for Medicare telehealth CPT addition of 17 codes to the E/M section for Telehealth Education for office staff Implementation on your software programs Who Will Benefit Physicians Advanced Nurses Physicians Assistant Billers Coders Compliance Managers Administrators Case Managers Claims Processors
HIPAA Breach Risk Assessments determine whether a Ransomware attack constitutes a HIPAA Breach that triggers Breach Notification Rule reports and notifications. A Ransomware attack is automatically presumed to be a HIPAA Breach unless you do a HIPAA Breach Risk Assessment that demonstrates the attack resulted in only a low probability of compromise to the affected protected health information (PHI). This webinar explains how to do a Ransomware HIPAA Breach Risk Assessment. The Problem Solved by this Webinar The HHS Office for Civil Rights (OCR) declared that a breach of unsecured PHI is presumed to have occurred when electronic protected health information (ePHI) is encrypted as the result of a ransomware attack on a HIPAA-regulated entity (health care provider, health plan, health care clearinghouse, or business associate). The entity must then comply with the applicable breach notification provisions, including notifying affected individuals without unreasonable delay, the Secretary of HHS, and the media (for breaches affecting over 500 individuals), in accordance with HIPAA breach notification requirements. However, it is not a breach if the ransomware-victimized entity can demonstrate that there is a low probability that the encrypted ePHI has been compromised. This webinar explains how to do that. Areas Covered in the Webinar A Breach Risk Assessment can determine whether a ransomware attack is a breach of unsecured ePHI, triggering embarrassing reports and notifications. Factors that can be applied in performing a Breach Risk Assessment. OCR’s guidance about specific factors that can demonstrate a low probability of compromise to ePHI encrypted by a ransomware attack. How to perform a Breach Risk Assessment step-by-step. How to document a Breach Risk Assessment and why you must document it. What to do if you cannot demonstrate a low probability of compromise to ePHI. Why You Should Attend This Webinar Attend this webinar to learn how to perform a Breach Risk Assessment with a special emphasis on ransomware attacks. Ransomware attacks may have only a low probability of compromising ePHI. A Breach Risk Assessment can determine whether a ransomware attack resulted only in a low probability of compromise to ePHI and provide Covered Entities and Business Associates with Documentation to overcome the presumption that the ransomware attack was a Breach.. Who Will Benefit Health Care Covered Entities HIPAA Compliance Officials – Privacy and Security Officers Chief Compliance Officer Practice Managers Health Information Technology Supervisors Risk Managers Group Health Plan Administrators Third Party Group Health Plan Administrators Covered Entity Senior Management and Owners Health Care Providers practicing as individuals or in small groups Attorneys for Covered Entities – In-house and Outside Counsel Business Associates HIPAA Compliance Officials – Privacy and Security Officers Chief Compliance Officer Business Associate Senior Management and Owners Risk Managers Attorneys for Business Associates – In-house and Outside Counsel
Over the last few years, the U.S. Department of Health and Human Services, Office for Civil Rights has made modifications to patient privacy requirements. The agency is on track for enhancing care coordination, empowering patients, and reducing administrative burden. In addition, on the Security Rule side, the agency released a proposed rule to overhaul significant requirements and make cybersecurity safeguards a priority. Knowing what an organization must do to meet these new regulatory requirements can be challenging. The webinar will address what has already changed in privacy, cover proposed Privacy Rule modifications, and cover the Security Rule overhaul proposals. Timeline and compliance implications will be covered. After completing this webinar, a Covered Entity or Business Associate will have a clear understanding of what has changed and what will change. Objectives Who Must Comply with HIPAA Requirements? What are the HIPAA Security and Privacy Rules? What Has Already Changed in Privacy? What are the Proposed Privacy Rule Modifications? What are the proposed Security Rule modifications? What is the Timeline & Compliance Implications? What recommendations should be followed now? Q&A Webinar Highlights Learn from an expert on the implementation of the HIPAA rules Understand what the HIPAA management process currently requires Learn how to implement these changes for your organization Who Should Attend Compliance Officer HIPAA Privacy Officer HIPAA Security Officer Medical/Dental Office Managers Practice Managers Information Systems Manager Chief Information Officer General Counsel/lawyer Practice Management Consultants Any Business Associates that access protected health information
Many providers have considered outsourcing functions in the revenue cycle. Like all businesses, some third-party companies do excellent work for providers, but there may be others that look for ways to take advantage of their provider. Outsourcing has its own pros & cons that must be carefully considered. We will review major common areas that providers must weigh strategically before making a decision whether to outsource and selecting the best partner for your needs. It is vital providers know exactly who is handling their claims and what they are doing with their information. Definitions of third-party vendors Legal responsibilities of the provider Common industry trends Important questions to ask vendors & contractors Who Will Benefit Physicians Practice managers Medical assistants Nurses Compliance staff Billers Coders Revenue Cycle Risk Management Mid level providers